Provider Demographics
NPI:1033311535
Name:CHARTER OAK ENDODONTICS, INC
Entity Type:Organization
Organization Name:CHARTER OAK ENDODONTICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAVELY-GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD , MS
Authorized Official - Phone:615-339-6592
Mailing Address - Street 1:PO BOX 3086
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37024-3086
Mailing Address - Country:US
Mailing Address - Phone:615-339-6592
Mailing Address - Fax:
Practice Address - Street 1:1926 HIGHWAY 46 S
Practice Address - Street 2:
Practice Address - City:DICKSON
Practice Address - State:TN
Practice Address - Zip Code:37055-2754
Practice Address - Country:US
Practice Address - Phone:615-446-7050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN80791223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty